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I'm getting tired of hearing what neurologists have to say about Terri Schiavo's CT of the brain. Real Tired. The Florida Sun Sentinel had a gang of neurologists analyze one of Terri's CT's of the brain. Here's what they said:

About 70 percent to 90 percent of Schiavo's upper brain is gone, and there's also damage to her lower brain that controls instinctive functions such as breathing and swallowing, said three Florida neurologists who viewed 12 of her CT "computed tomography" X-ray scans Tuesday and Wednesday.

"This is as severe brain damage as I've ever seen," said Dr. Leon Prockop, a professor and former chairman of neurology at the University of South Florida College of Medicine in Tampa, upon viewing the scans.

Then there's the infamous Dr. Ronald Cranford, who has the double-whammy credentials of neurologist AND bioethicist (have you had enough of bioethicists for a while? Why is it they all have the same opinion and they all start out their spiels by saying "this is a tragic case for everyone involved...") who also defined Terri's CT of the brain as being as bad as he's seen.

So What Have You Seen?

I've watched a steady stream of neurologists, bioethicists, and neurologist/bioethicists from Columbia, Cornell, and NYU interviewed all week on Fox and CNN and MSNBC. They all said about the same thing, that Terri's CT scan was "the worst they'd ever seen"or "as bad as they've ever seen."

Here's the problem with these experts: THEY DON'T INTERPRET CT SCANS OF THE BRAIN. RADIOLOGISTS DO.

*Oh*

You see, a neurologist will look at the CT of the brain of one of his patients, but this is entirely different from interpreting CT's of the brain de novo, for a living, every day, without knowing the diagnosis and most times without a good history. In addition, whereas I heard Dr. Crandon say he's "seen" a thousand brain CT's... well I've interpreted over 10,000 brain CT's. There's a big difference.

When I look at a CT of the brain every case is a new mystery about a patient Idon't know. I must look at the images, come to a conclusion, dictate my findings and report a conclusion. This becomes a part of the official legal record for which I am liable. I bill Medicare for a CT interpretation and am paid for this service.

Neurologists do not do this. They don't go on the record, alone, in written legal documents stating their impressions about CT's of the brain. The neurologist doesn't get sued for making a mistake on an opinion of a CT of the brain THE RADIOLOGIST DOES.

A neurologist has no where near this type of practical experience. And their cases are skewed according to where they practice and what their specialty is. Now, some of my best friends and some of the smartest docs I eve4r met are neurologists, but that doesn't change my observation that most neurologists I've met, in my experience, show an incomplete grasp of the nuances involved in image interpretation.

I have seen several neurologists -- in the printed media and on television -- put up a Representative CT of the brain of a normal 25 year old female and contrast this with Terri Schiavo's CT. This is a totally spurious comparison. No one is disputing that Terri Schiavo does not have the CT of a 25 year old female.

What I'm saying is that Terri Schiavo's CT could be the brain of an eighty or ninety year old person who is not in a vegetative state. THOSE are the CT scans we should be showing next to Schiavo's, because in THAT case you would see similar atrophy and a brain much closer to Schiavo's.

Who Wants To Be A Millionaire?

To prove my point I am offering $100,000 on a $25,000 wager for ANY neurologist (and $125,000 for any neurologist/bioethicist) involved in Terri Schiavo's case--including all the neurologists reviewed on television and in the newspapers who can accurately single out PVS patients from functioning patients with better than 60% accuracy on CT scans.

I will provide 100 single cuts from 100 different patient's brain CT's. All the neurologist has to do is say which ones represent patients with PVS and which do not.

If the neurologist can be right 6 out of 10 times he wins the $100,000.

Comments

A major point is that the CT is not part of what leads to the diagnosis in my understanding. Check the Cecil Textbook of Medicine, 22nd edition, page 2276 and pay particular attention to the part that says "Results of brain imaging studies depict the sequelae of the causative injury but are not diagnostic of a persistent vegetative state." I believe that the flat EEGs referred to in the court documents are usually considered more telling of Mrs. Schiavo's condition by the neurologists, as well as physical exam findings. Read page 2276 again and pay attention to how similar what's described is to how Mrs. Schiavo appears on the circulating video.
And, again, as has been asked several times by several people posting to this site, let's see the scans of these 80 year old patients that are comparable to Mrs. Schiavo. And, while you're at it, why not give an actual report on the CT that may or may not be Mrs. Schiavo's. Type up what you would submit into the chart if you were reading this film, because you haven't done that yet either. (As best you can from one image.) How would you describe the cortex posterior to the ventricles? Where is her corpus callosum?
Also, I've seen a neurologist's record in a patient's chart disagreeing with the radiologist's interpretation of an MRI. Hmm, a neurologist putting his interpretation of a radiologic image in the legal document such that he might be sued over it. I thought that didn't happen. In my limited experience I've seen this done on several occasions by different docs.
But, back to the main point, the CT scan doesn't really play any part in the diagnosis of PVS, it only provides visualization of the extent of physical injury. Check page 2276 of Cecil again and see how PVS is diagnosed. This is a nice hollow challenge you've issued. No one who understands how the diagnosis of PVS is made would accept it.
I'm sure that many neurologists would be just as critical of your ability to describe state of consciousness in a patient as you have been of their ability to read films. And, since you've displayed complete ignorance of the criteria, I'd say they have a pretty good case.

I heard Beatrice Engstrand (neurologist to the Central Park Jogger) say something about how knowledge of the brain doesn't translate to understanding of the mind. That made me reflect on the following (bizarre and extreme, I know), and I wanted you to see it.

"Do you really have to have a brain? The reason for my apparently absurd question is the remarkable research conducted at the University of Sheffield by neurology professor the late Dr. John Lorber.

"When Sheffield’s campus doctor was treating one of the mathematics students for a minor ailment, he noticed that the student’s head was a little larger than normal. The doctor referred the student to professor Lorber for further examination.

"The student in question was academically bright, had a reported IQ of 126 and was expected to graduate. When he was examined by CAT-scan, however, Lorber discovered that he had virtually no brain at all."

The most criminal part of this whole case, other than watching this killing, is that Terri Schiavo was denied any therapy. Nobody can say to what degree she may have recovered because Michael Schiavo would not allow it, though therapy was indeed recommended.

I have seen a comment suggesting that the EEG is useless as a diagnostic tool because when it was taken Terri had too much movement in the muscles and that movement had to be filtered out. This led to the flat EEG result.

I would like to see Dr. Hammesfahr take up your challenge.

I think that you have a very good point about the manner in which this is being handled. At this time there is still the possibility that the cut does not belong to Terri.

As for the med student who says that you have not made a comment about that cut, he should go back and read your comments, especially to the fact that the CT scan indicates a hydrocephalus brain. I thought that this is exactly what it means to interpret scan results.

Keeping in mind I am not a medical person, but I am very interested in these comments.

1. I nowhere, ever said that a CT of the brain was the appropriate tool to diagnose PVS. YOU ARE MAKING MY POINT. *duh* It certainly IS NOT the appropriate modality for making this determination, as I must intend when I plainly state that I have seen people with similar atrophy who are NOT in a persistent vegetative state, right? THAT'S THE POINT.

2. I described what I thought of the cortex posterior to the ventricles in my post regarding hydrocephalus.

And where is her corpus callosum? I dunno, do you know where YOURS is? The corpus callosum is a higher parasagittal midline structure; however it is an antero-posteriorly oriented band that is not well visualized with the transversely oriented CT imaging. What you might see of it is not located at the anatomic level of the image we've been discussing.

3. You said: "Also, I've seen a neurologist's record in a patient's chart disagreeing with the radiologist's interpretation of an MRI"

You are a little concrete, are you not? Are you saying that you do not understand what I intend when I say that my primary job is to pick up CT's all day long and officially interpret them for the medical record? That's why I get called into court EVERY WEEK, because my name is on every chart as the interpreter of record for the studies. THEY DON'T CALL THE NEUROLOGISTS WHEN THEY ARE SUING OVER A CT. They call me. This FACT does not prevent any doctor at any time writing any thing he or she wants in the chart, or on the bathroom wall for that matter. And I never said that the radiologist is always right or the neurologist is always wrong -- my point was that neurologists are trotted out to interpret Terri Schiavo's CT in the MSM, yet, THIS IS NOT THEIR JOB AND THERE ARE PHYSICIANS OUT THERE WHO DO IT BETTER.

I have never mentioned TS's EEG BECAUSE I DON'T LOOK AT EEG'S OFFICIALLY FOR A LIVING. Neurologists don't look at CT's, officially, for a living.

You talk as if I owe it to you to make sure everything that I say is verified in your mind.

Yet,what I am providing here is information that you can only get from someone who has ten years of training at the world's top medical institutions, and fifteen years of experience in a busy medical center. My expertise is not common, is not easily come by, and is generally not offered to the public free of charge.

Do you see any ads on this page? No. Do I write this blog for money? No. Why do I do this? Why have I spent hundreds of hours in the middle of the night and between cases at work to write this blog?

One reason is because of the total horror I experience every time I read medical "news" in the MSM. They always get it wrong. They never ask the right questions. YOU ARE ALWAYS IN THE DARK.
Why is that? Because those reporting the news (and managing your health care)have little regard for your intelligence. It is believed that the average American is so dumb that he or she cannot possibly manage this information -- so WE have to do it for you. And WE are leading YOU and the AMERICAN HEALTH CARE SYSTEM to the slaughterhouse on the way.

I am trying to WAKE YOU UP before you get there.

For everyone's information, not only have I put my money where my mouth is, but I have put my credentials and reputation on the line as well. I have officially and legally declared my thoughts on Terri Schiavo's radiological studies on a legal document for the courts of Florida.

Your efforts are very appreciated by me. I have a couple of physicians in my family but the medical lingo is still hard for me to follow. Thing is, I get the BIG picture and it scares the shit out of me.

Dr.Boyle, I'm sure no one questions your expertise examining IMAGES-to even hint that may be true is creating a straw man.While conspiracy theories are certainly titillating,your extrapolation based on reading a SINGLE slice of a SINGLE scan is exactly that-I would suggest that a CLINICAL exam done by a NEUROLOGIST on the PERSON imaged is more persuasive than your interpretation of scant data.Furthermore,I would submit that a NEUROLOGIST'S ability to interpret BRAIN imaging,particularly one with the LONG experience of Dr.Cranford -I'd be willing to bet he's seen,oh, maybe 10,000 scans in his career-is very near that of a radiologist.And speaking of bets,your public throwdown to all and any neurologists is a little unseemly for a professional of your stature,not to mention a red herring.As I suggested above,neurologists rely on BEDSIDE exams for their diagnosis, using imaging,EEG,etc. as TOOLS(however indispensible those TOOLS may be).I,too,would be interested in some follow up on the legions of 80 and 90 year olds with similar scans,and the level at which they function-WALKING?TALKING?Trying to imagine what they look like brings to mind crowd shots from Night of the Living Dead.One last suggestion-scale back on the use of CAPITALS-it makes it seem like you're screaming at us.I really enjoy your blog and appreciate the effort it takes.

I, for one, certainly want to thank you for your efforts with the material you provide on this website. I don't like being kept in the dark about health issues and have enough experience with stressful medical emergencies to understand the value of this type of review. My mom suffered a brain aneurysm with surgery that resulted in a subsequent stroke leaving her a hemiplegic. My daughter had a coarctation of the aorta requiring two surgeries to save her life following birth. She is about to graduate high school and is doing well now.
I wish this type of information was available online back then.
I don't have a crisis to deal with now, but appreciate having this material available to the lay person for review. I hope I will not need it, but if in the future this information becomes useful - it will only be because you took a great deal of time and effort to put it online for us.
CODEBLUEBLOG- THANK YOU!

I don't believe any neurologist in public has claimed Terri is in PVS simply b/c they saw one slice of a scan.

The article makes it very clear that the neurologists looking at those scans felt that there was severe damage. They said nothing more and nothing less. You wouldn't diagnose PVS from a CT and neither have they.

I think the blog article is stating the same thing you are. A CT scan, let alone one slice, is NOT enough to diagnose someone as PVS. His contention is that the mainstream media is interviewing neurologists and parading this one slice as proof that Terri is so damaged that she's PVS. The lay public is not likely to recognize the nuances that these neurologists are not diagnosing PVS. They'll hear such extreme statements as "more damage than I've ever seen"...and draw conclusions that this is proof that Terri is "brain dead" or vegetative.

Why neurologists are willing to be interviewed in such a public and potentially exploitive way is beyond me. Perhaps their comments that despite the damage they see, they cannot diagnose someone by that one slice, are being edited out of the interiews. It's probably not compelling/titillating news to have someone say that EEG, MRI, etc and clinical bedside evaluation are also required. And it's probably not likely to be the story the media wants if someone were to say that despite the damage being horrific, Terri *might* still be conscious or aware.

Despite my not having seen these interviews, I'm postulating that there may be some creative editing. But back to the original blog post you're commenting on. I think if you'll re-read the article, you'll see that you and Ryan (is that his name?) are on the same page.

Actually, I don't know the first name of CBB's author. I'll just refer to him as doc or CBB.

At any rate, most of the complaints about the challenge aren't quite realizing that they're saying the same thing as CBB. Your arguments that radiologic interpretation of the scans isn't enough to diagnose whether someone is PVS or not is exactly what the challenge is about. CBB is also saying that it's not enough and he's daring anyone to try to diagnose PVS at a 60% accuracy based on just CT scans.

Actually, I don't know the first name of CBB's author. I'll just refer to him as doc or CBB.

At any rate, most of the complaints about the challenge aren't quite realizing that they're saying the same thing as CBB. Your arguments that radiologic interpretation of the scans isn't enough to diagnose whether someone is PVS or not is exactly what the challenge is about. CBB is also saying that it's not enough and he's daring anyone to try to diagnose PVS at a 60% accuracy based on just CT scans.

Susano - Terri recieved 24 hour intensive physical, occupational, recreational and speech therapy in the first few years of her treatment. She was also flown to California for experimental treatment (that's the white mark you see in the CT scan), so to say she was "denied any therapy" is wrong. It was stopped, but she did recieve therapy.

I say this because is counterproductive to Terri's cause to say things that are verifiably untrue, and it urks me when I see people repeat similar statements. The truth can save Terri.

CodeBlueBlogMD - I have a question about the CT scan. I have seen scans of other patients with hydrocephalus who are walking, talking, and generally functioning put alongside them for comparison (online, not on MSM). But while the pool of fluid is relatively the same sise, the outer parts of the brain are still firm and spongey on the functional ones. On Terri's CT scan from 1996, the outer parts of the brain are very loose and stringy.

Is this something I'm viewing wrong (I'm not an MD) or does it indicate the damage is more extensive? Or does it mean nothing? I understand that, in either case, the brain will try to rewire itself through whatever is left.

Thank you Ceci! YOU UNDERSTAND! I feel like Annie Sullivan as Hellen Keller mumbled the first words of understanding.

That's exactly what I'm getting at!

It isn't ME whose drawing all these conclusions from that one dumb CT slice...it's THEM!

I nowhere say that the CT slice diagnoses or does not diagnose PVS. Nowhere. I was drawn to the scan by a bioethicist's comments on NPR. He said TS's brain was a "bag of water." When I saw that scan slice I said "Oh no it's not." Period. I also said that there are people out there who are not in a PVS with similar scans. I didn't say they were composing symphonies or designing rocket launchers. No. They are impaired. Many severely. But don't you see what I'm trying to say? What are we going to do with those people? Starve them?

Ceci hit the nail on the head. It is the irresponsible reporting that I protest. It is the careless characterization of the CT that got me going.

Once I started to look into this case, however, I came across a lot of things that were wrong, or did not make sense. The bone scan findings, to me, are outrageous and cannot go unexplained, especially since they strongly suggest abuse.

The "normal" CT of the brain -- on 2/27/90, 2 days after a supposed global anoxic event -- is completely and utterly impossible. If we are to believe that TS's brain damage and cortical atrophy are a direct result of global brain oxygen deprivation on 2/25/90, then cellular damage begins immediately, is visible on MRI (as "edema" or water leaking out of brain cells)in 20 minutes, and withing 24 hours Terri's brain would have manifested gross edema and swelling on the CT. By 48 hours the brain should have been massively swollen -- nearly bursting out of the skull. Many of these patients have to have a piece of the skull temporarily removed at this point just to accommodate the swelling. The CT couldn't be normal.

I ask questions when I don't have the answers. I ask qurestions when things don't make sense. If someone sets me straight, I'll admit to it.

But this is not a professaional journal, it's a blog. I think one of my functions here is to pluck these questions out of these cases and make people answer them if I can. Then YOU learn.

Would you rather I just blog the news or comment on the next study that shows what causes cancer and what makes you fat?

I'm TRYING to shake things up because I believe that those in the news and those writing the news need to be way better than they are. I'm looking to change things.

Was it really 48 hours? Or was it more like 36 hours? I realize it was technically 2 days later--but we don't have a time frame (do we??).

According to my path book (this is great, I get to study for Friday's test and blog!):

"In the period immediately after a global hypoxic-ischemic insult, the brain may appear normal, both grossly and microscopically. In the case of patients who survive the acute insult, within 24 to 48 hours, the brain is softened and edematous."

I assume the book means this is when gross appearances change...i.e. when CT shows up. And it appears that it takes 12-24 hours for microscopic changes in a situation like this (an infarct is different--those move quicker microscopically).

Is it possible that b/c she was young and vibrant, it took longer than 36 hours to become noticeably edematous?

But back to my previous comment, I don't read these stories as if doctor's are on television saying "she's clearly PVS b/c I've seen that CT slice". That's just not what I'm hearing or reading. What I'm hearing and reading is "there is clearly significant damage". And then especially from Cranford: "damage + eeg + physical findings=PVS". I don't see anyone claiming damage=PVS. I see them claiming...well...they say she's in PVS and this CT could go along with that diagnosis.

I suppose it's a fine line--but I don't feel like anyone has crossed it.

Bottom line, a CT cannot be used for diagnosing PVS, which is why people have been calling for an MRI and/or a PET/PEP to determine her true brain function. As another poster stated, the EEG results are inconclusive because they filtered out tremor. A PET/PEP would completely clear up the issue of her brain function, yet it's been completely denied.

Incidentally, to the poster who stated that a complete eval was done, that's hogwash. The only doctors that have spent more than an HOUR with her (and I'm speaking to those whose opinions were used in the court ruling only) were the docs that said she was NOT PVS. I have investigated this pretty thoroughly, and brain injured patients do not have a normal sleep/wake cycle, and they often are aphasic so it takes a lot of time to do an adequate assessment. You have to repeat something several times over several days to see if there's a pattern to the patient's responses, and see if you're truly catching them in a fully alert status.

There is so much of this case that stinks. And I'm tired of hearing people spout medical crap that's just that... CRAP, because they heard a doctor on TV say it.

Disclaimer: I am a medical amateur. I was a pre-nursing student and a paramedic, so I know how to research medical issues. I can't diagnose anything and am not a doctor, but I know enough to research what the docs are saying and see if it holds water with what the experts in that field are saying.

Jeremy at last you are thinking about the case, but I do not think that you have quite grasped the inaccuracy of Cranford's diagnosis.

Since I am not a doctor, all I can do is look at what is presented and pick out the holes. In this particular case there are a lot of anomalies that have to be explained.

From my point of view, the first thing that should be questioned is the information that this woman suffered a heart attack that was the result of bulimia. The investigations that I have so far completed leave me to believe that she was not bulimic. Also she did not have a heart attack.

The reason that I do not believe that she was bulimic in the first place, is that she was treated by the hospital with FLAGYL for an enteric infection that did show up in her pathology tests. FLAGYL is used to treat a parasite known as Guardia. (sp). Since I have had two bouts with this particular parasite I do know how it upsets one's stomach, causing stomach cramps etc. It also causes the person to vomit. Also it is not a 24 hour virus and if untreated can last for several weeks. It is possible that Terri had this bug for several weeks and that is why she was only drinking iced tea. That on my part is speculation.

If there was no heart attack then why the brain damage? That is a good question and it needs a thorough investigation. One possibility, and it was admitted on oath, is that Terri's brain suffered a severe whiplash when Michael shook her after the collapse. If for example, she had a torn neck muscle as a result of this whiplash, there is a probability that it was bleeding. Since I am not a medical person I cannot complete any further logical deductions about whether or not there is a possibility that a torn neck muscle could be behind the later bleeding and abnormalities that were not present within the first 48 hours. This can only be answered by experts in the field who deal with both whiplash injuries as well as shaken baby syndrome.

The next problem with this case is that after the malpractice money was received all therapies and treatments were stopped. Michael Schiavo attempted to prevent his wife receiving antibiotic treatment for a UTI in the hope that she would develop blood sepsis and die.

Also, as an observer, if this woman was really brain dead, why is it that she has not died after 13 days of starvation and dehydration. If she were truly brain dead, then surely the lack of nourishment would mean that she would have died at an earlier stage.

With regard to the EEG that was flat, I think that what should have happened is that a new one was ordered by the doctor. If you read what Dr. Hammesfahr stated on this matter, it seems that there was too much muscle activity and when that was filtered out, so was the other information. In other words it looks like the EEG was for all intents and purposes useless.

What you, as a trainee med student should be seeking in a situation like this, is to sift through and examine all angles before jumping to conclusions. Only by further investigation will you be able to show that all avenues have been exhausted and there is not a wrong diagnosis due to expediency.

Do you mean Dr. Cranford where you say,"whereas I heard Dr. Crandon say he's 'seen' a thousand brain CT's. . ." Also, after the CT myth is dispelled they will start carping on the purported EEG. I have not found much info on this except that movement might cause "artifact" that when screened out can mask other brain activity. I have heard she has had several EEG's but— could you comment? I must admit I have not finished reading this most recent post so if you addressed this I apologize.